DefinitionI.V. moderate sedation should producean altered sensory condition in whichthe patient exhibits an altered(depressed) level of consciousnesswhile maintaining the ability toindependently and continuouslymaintain a patent airway and respondappropriately to verbal stimuli.
Protective ReflexesLoss of reflexes, including theinability to maintain a patent airwayand/or purposeful response tophysical and/or verbal stimulation asa result of a systemicallyadministered drug.
LocationOperating RoomPACUEndoscopyOutpatient CenterCritical Care Unit (ICU)Emergency Department
ScopeAll moderate sedation will be orderedand directly supervised by thephysician performing the procedure.Administration and/or monitoring ofmonitored sedation may be performedby a qualified physician privilegedor a registered nurse trained inadministering or monitoring conscioussedation.
ScopeA physician may waive NPO guidelinesunder any emergency conditions, whichwill be noted in the medical recordPatients with severe systemic diseasepresent on the day a procedure undermonitored sedation is scheduled mayrequire a sub-specialty consultationand/or anesthesia provider
ScopePatients with severe systemic diseasepresent on the day a procedure undermonitored sedation is scheduled mayrequire a sub-specialty consultationand/or anesthesia provider
ScopeAny Patient Receiving Propofol orKetaminePatients under 60 years of age whoreceive intravenously >5mg of Versedor >20mg of Valium.Patients 60 years of age and olderwho receive intravenously >2mg ofVersed or >10mg of Valium
ScopePatients receiving any combination ofIV narcotic and Versed or Valium.
Pediatric Patients Demerol combined with Phenergan orThorazine. Chloral Hydrate PO Fentanyl PO Versed Rectal Brevital
Physician ResponsibilitiesProviding the level of monitoringspecified in these guidelines and tomanage complications.The practitioner should be trained inand capable of providing basic lifesupport (ACLS Recommended)
Physician ResponsibilitiesBeing present when medications formoderate sedation are administered.Be within immediate reach andavailable on the hospital premises ifproblems or emergencies arise.
Physician ResponsibilitiesAuthorizing the administration of thesedation within the recommendedsedation dosage guidelines.Writing a post-procedure note anddischarge orders.Determining that the patient is anappropriate candidate for thesedative agent to be administered.
Pre-Procedure EvaluationPatient’s ageChief complaintCurrent medicationsHistory of medication allergies/reactionsOverall physical status
Pre-Procedure EvaluationConcurrent medical problemsHistory of substance abuseVerification of patient compliancewith pre-procedure instructions(Informed Consent for the procedureto be performed)
Pre-Procedure EvaluationDiscussion of risks, benefits, andalternativesPhysical examination pertinent to thehistory and procedure to be performed
ASA ClassificationClass I normal healthy patientClass II patient with mild systemicdiseaseClass III patient with severesystemic disease with functionallimitationsClass IV patient with severesystemic disease that is constantthreat to life
RN ResponsibilitiesAdequate transportation andpostoperative care arrangements madefor discharge.History and Physical present in themedical record.Proper consent(s) signed for theprocedure.
RN ResponsibilitiesVerify the patient has been NPOVerify allergies.Verify pregnancy statusAssure recent lab results areavailable in the medical record.Document baseline vital signs
RN ResponsibilitiesDocument baseline SaO2 (room air ifO2 therapy not being implemented)Complete a pre-procedure assessment.Assure a patent IV accessVerify equipment is functioningproperly prior to use.
RN ResponsiblitiesDocument emotional state.Document level of consciousness.Document skin signsVerify perceptions regardingprocedures and level of sedation.
Goals And ObectivesAllay patient fears and anxietyregarding the planned procedure(s)Alteration in moodMaintenance of consciousnessCooperationElevation in pain threshold
Goals And Objectives Minimum variation of vital signs Amnesia Rapid, safe return to ambulation
RN ResponsibilitiesAdminister medications as directed bythe privileged physician present.Notify physician of any significantchange in the patient’s physiologicstatus.
RN ResponsibilitiesThe nurse managing the sedation ofthe patient shall have no otherresponsibilities that would interferewith continuing monitoring care,physical care, and emotional support.
EquipmentOxygen delivery in placePulse oximetry equipment in placeAn I.V. access line established andpatency maintainedCardiac and blood pressure monitoringin place
Equipment (Present & Available) There shall be an emergency code cart immediately available with emergency resuscitative drugs and defibrillator. Oxygen and appropriate O2 delivery systems Suction and appropriate suction equipment
Equipment (Present & Available) Bag, valve, mask breathing devices Oral/nasopharyngeal airways and endotracheal tubes of various sizes Sphygmomanometer and/or non-invasive blood pressure monitor EKG monitor
Continuous MonitoringDesired therapeutic effectsAdverse effects with appropriateintervention/prevention of theseadverse effects.Early detection of non-preventableadverse effectsPatient’s response
Continuous MonitoringAssess and document vital signs at aminimum of every 5 minutes or morefrequently during drug administrationand during the procedure.
Post Procedure MonitoringVital signs (BP, EKG/HR, RR)Oxygenation (SaO2)Level of consciousness and Return topre-sedation status
Post Procedure MonitoringAssess and document vital signs at aminimum of every 15 minutes x 2, thenevery 30 minutes x 2, then every hourx 2, then every 2 hours x 4Continuous SaO2 monitoring for aminimum of 30 minutes, recheck anddocument SaO2 immediately prior todischarge
Transfer RequirementsO2 saturation maintained at pre-procedure level or >92%, with orwithout oxygen, at a respiratory rateof 12 or greaterIntact protective reflexes, muscularstrengthAble to cough and/or demonstrate gagreflexes
Transfer RequirementsRespond to verbal commandsMaintain patent airway, independentlyand continuouslyAbsence of restlessness, cyanosis,pallor, flushing, diaphoresis, orpalpitationNo evidence of bleeding
Discharge CriteriaConsciousness: Awake and respondingappropriately, > 1 hour post reversaldrugCirculation: BP within acceptablepre-operative levelsOxygen saturation > or = to 95% inthe unstimulated patient on room airor equal to pre-procedure saturation.
Discharge CriteriaFluid intake: Taking P.O. fluidswithout nauseaActivity level: Ambulate withminimal assistance with stable BPBody functions: Patients who haveundergone regional anesthesia,urological, gynecological, or herniaprocedures must be able to void
Discharge CriteriaStable wound sitePain within tolerable limits with/without P.O. medicationAdequate neurovascular status ofoperative extremity (if applicable)Modified Aldrette score of 8 orgreater
Dishcarge CriteriaIf the patient does not meet theabove criteria, a discharge ordermust be obtained from the surgeonand/or consulting Anesthesiologist/CRNA.If the above criteria are not metafter four hours, the attendingphysician should be notified.
DocumentationThe Local/ Moderate SedationOperative Record will be utilized forall patients receiving conscioussedation in every patient care area.
DocumentationThe Emergency and Critical CareDepartments may utilize only thegraph portion of the Local/ MonitoredSedation Operative Record if allother pertinent information isdocumented on the EmergencyDepartment Clinical Record or theCritical Care Flow Sheets.
DocumentationShall reflect evidence of continuousassessment, diagnosis, outcome,identification, planning,implementation, and evaluation ofcare
DocumentationPatient care management immediatelybefore administration of monitoredsedation drugs, during the sedationphase, and immediately post-procedure(recovery).Dosage, route, time and effects ofdrugs usedType and amounts of fluids
DocumentationPhysiologic data from continuousmonitoring at a minimum of 5 minuteintervals and with any significantevent during the procedure.Level of consciousness
DocumentationSignificant adverse patient eventswith corrective action taken andeffects of action taken.Condition at transfer in the eventthe patient is transferred to anotherpatient care area
Reportable ConditionsDeep sedation (unintended)Unexpected Phase I recoveryAssisted Ventilation is required.There is an unanticipated hospitaladmission and/or an increased levelof care required
Reportable ConditionsAny case in which the SaO2 remains <90% or 3% less than baseline for morethan three (3) minutes after O2administration.Any case in which SaO2 is 80% or lessat any time.
Reportable ConditionsAny case in which there ishemodynamic instability (defined as a20% change from baseline bloodpressure or heart rate) requiringmedications and/or medicalinterventions.A reversal agent is administered
Reportable ConditionsLack of adherence to hospital policyon Moderate Sedation.ET intubationCardiac arrestAdverse medication reaction
Reportable ConditionsProlonged recovery from sedation (> 2hours post procedure)Patient, family, or staff complaintregarding quality of sedation/analgesia.Unexpected need for Anesthesiologist/CRNA
QualificationsPhysicians intending to use agentsfor the purpose of monitored sedationmust be specifically privileged.Anesthesiologists, CRNAs, BoardCertified Physicians in Critical Care(Adult & Pediatric) and BoardCertified Physicians in EmergencyMedicine will be granted privileges.
RN QualificationsRNs who monitor patients receivingI.V. moderate sedation will havecompleted competencies in ModerateSedation.The nurse monitoring the patient careshall be aware of the desirable andundesirable effects of I.V. moderatesedation.
RN QualificationsThe nurse shall have the knowledgeand skills to intervene in the eventof a complication.
Desirable EffectsIntact protective reflexesRelaxationCooperationDiminished verbal communicationEasy arousal from sedation
RN QualificationsThe nurse monitoring the patientshall have a working knowledge ofresuscitation equipment and thefunction and use of monitoringequipment and should be able tointerpret the data obtained.
RN QualificationsThe nurse shall demonstrate skills inbasic life support and have CurrentBLS recognition. ACLS isrecommended.
RN QualificationsAnatomy and physiologyPharmacology of drugs usedCardiac arrhythmia interpretation
RN QualificationsComplications related to the use ofI.V. conscious sedationPrinciples of oxygen delivery andrespiratory physiologyDemonstrate knowledge of properdosages, administration, adversereactions, and interventions foradverse reactions and overdoses.
RN QualificationsAssess total patient carerequirements or parameters, includingbut not limited to respiratory rate,oxygen saturation, blood pressure,cardiac rate and rhythm, and level ofconsciousness.
BenzodiazepinesMost common are midazolam (Versed®),diazepam (Valium®), and lorazepam(Ativan®)Most often administered for sedationand amnesia or as adjuncts to generalanesthesia (usually a pre op med)
BenzodiazepinesCNS – amnestic, anticonvulsant,hypnotic, muscle relaxant, andsedative effects in a dose dependentmanner.Cardiovascular – mild systemicvasodilatation and reduction incardiac output (more pronounced withadded narcotic)
BenzodiazepinesRespiratory – mild decrease in RR andtidal volume (more pronounced withadded narcotic)Reversal of benzodiazepines isaccomplished with flumazenil ifneeded (antagonist)May cause venous irritation
NarcoticsFentanyl and sufentanil are the majornarcotics used intraoperatively.Morphine, demerol, and fentanyl arethe major narcotics usedpostoperatively.In high doses, narcotics areoccasionally employed as the soleanesthetic (e.g. cardiac surgery)
NarcoticsPrimary effect is analgesia, andtherefore they are used primarily tosupplement other anesthetics duringinduction or maintenance of generalanesthesia.
Narcotics CNSSedation and analgesiaEuphoria also common.In large doses amnesia and loss ofconsciousness.Demerol can cause Seizures
Narcotics CardiovascularSVR moderately reducedDemerol a direct myocardialdepressant.Enhance myocardial depressant effectsof other anestheticsBradycardia in a dose-dependentmanner (eg fentanyl)Morphine and Demerol can causehistamine release
NarcoticsRespiratory depression in a dose-dependent manner.Miosis may be a useful guide in theassessment of narcotic effectMuscle rigidityNausea and vomitingUrinary retention
PropofolUsed for induction and/or maintenanceof general anesthesia.Also used in lower doses for sedation
PropofolRapidly induces unconsciousness withrapid recovery due to redistributionof the drug.Decreases in arterial blood pressureand cardiac output in a dose-dependent manner (cardiovasculardepressant).Dose-dependent decrease inrespiratory rate and tidal Volume.